Giant calculus in the submandibular salivary duct: report of the first prepubertal patient.

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Dear Editor, Sialolithiasis is rare in children. A review of the world literature revealed fewer than 120 cases of submandibular salivary calculi in children aged 3 weeks to 15 years [1]. Still more uncommon is the formation of giant stones. Since 1942, about 50 cases of giant submandibular calculi have been documented in the world literature [2, 3], but none of them occur in children. We recently encountered a 10-year-old girl whom we believe to represent the first case of submandibular megalith in the prepubertal age group. The 10-year-old girl was admitted because of a painless swelling in the floor of her mouth for several years. She denied any pain during meals. A week before admission, the swelling became acutely painful. Local examination revealed a 6·4 cm swelling on the right side of the floor of the mouth (Fig. 1). Because the mucosa over it was inflamed, the orifice of the Wharton’s duct could not be seen. There was no purulent discharge. Because of acute tenderness, the patient did not allow palpation of the swelling. A moderate degree of trismus was also noticed. A radiograph of the mandible showed a radio-opaque shadow consistent with a salivary stone (Fig. 2). Serum biochemistry did not reveal any underlying metabolic disorders. The patient was initially treated with intravenous antibiotics (ampicillin plus gentamicin), analgesics (paracetamol), and povidone–iodine mouthwash. On the 5th hospital day she was posted for transoral sialolithotomy. Bimanual palpation under general anesthesia confirmed a hard stone in the right submandibular duct. Mucosa overlying the posterior end of the stone was found to be eroded. Mucosa over the stone was incised along the course of the submandibular duct, and the calculus was extracted. After saline irrigation, the duct was marsupialised. The patient recovered uneventfully. The stone (Fig. 3) measured 3.5·2.5·2 cm and weighed 22 g. It was brownish-yellow, smooth in surface, and pear-shaped. Its physical features were consistent with a calcium phosphate calculus. At followup after 3 months, the patient was asymptomatic, and there was good salivary flow from the homolateral gland. Salivary stones that exceed 15 mm in any one dimension or one gram in weight are classified as giant [2]. In the pre-antibiotic era, sialoliths as heavy as 93 g were reported [2, 3], but in modern days they seldom exceed 20 g [2]. The largest salivary calculus reported in recent years was 6.5·5.5 cm [2, 3]. The youngest patient reported to have submandibular megalith was a 16-yearold African boy [4]. We believe that ours is the first case of giant salivary calculus in the prepubertal age group. Apart from its huge size, the stone reported herein has several interesting clinical features. Salivary calculi are classified as ductal (85%) or intraglandular (15%). The latter do not cause obstruction to the flow of saliva. Consequently, they remain silent for many years and attain a large size. In contrast to this, ductal stones—even when they are tiny—draw attention by producing salivary colic during meals. It is unusual that in our patient the ductal stone was asymptomatic for several years. It is generally believed [5] that salivary stones grow at a rate of 1–1.5 mm per year. In our case, the 35·25 mm stone occurring in a 10-year-old girl cannot be explained by simple mathematical extrapolation, unless the stone is assumed to be of neonatal or infantile origin. Only a very few cases of infantile sialoliths are reported in the literature. Traditionally, ductal stones are extracted by transoral sialolithotomy, whereas intraglandular calculi require V. Raveenthiran (&) 7, Medical Faculty Quarters, Annamalai Nagar, 608002, Tamilnadu, India E-mail: vrthiran@yahoo.co.in Tel.: +91-4144-239568